Erosive pustular dermatosis of the scalp: a pathogenetic mystery and therapeutic challenge.

Erosive pustular dermatosis of the scalp (EPD) is a rare condition that affects predominantly the adult population and occurs on a previously photo-damaged bald scalp. The physical examination is presented with large erythematous, erosive and crusted patches with granulation on an atrophic skin. The problem in patients with erosive pustular dermatosis of the scalp arises from the non-specific clinical and histopathological findings, which can be misleading. Biopsy followed by careful histopathological verification is mandatory, although the finding is nonspecific. The histopathology findings are characterized by superficial erosions with mild neutrophil infiltrate, mainly intravascular and focally with neutrophil exocytosis; focal parakeratosis, smoothed rete ridges without pronounced interface changes; pronounced lymphoplasmacytic infiltrate with focal distribution in the dermis and giant cell reaction with the formation of a "foreign body" granuloma.. We report a 58-year-old male patient with a 1-year-old lesion, suspected for skin cancer, later diagnosed with EPDS, which was successfully treated with topical clobetasol proprionate after 3-5weeks.

Primary Cutaneous CD30+/ALK- ALCL with Transition into sALCL: Favourable Response after Systemic Administration with Brentuximab Vedotin! Unique Presentation in a Bulgarian Patient!

BACKGROUND: Modern drugs could sometimes be a good solution even to problematic patients. The cutaneous and systemic forms of the CD30 positive anaplastic large T-cell lymphoma could often be described as a suitable target for therapy with Brentuximab vedotin. CASE REPORT: We present the first case of a Bulgarian patient with a histologically confirmed primary cutaneous T-cell CD30+/ALK- large anaplastic cell lymphoma-cALCL (therapeutically resistant to therapy with Methotrexate, radiation therapy and systemic corticosteroid therapy) who was successfully treated with Brentuximab vedotin. In several years, the patient has developed a comparatively fast skin progression as well as an initial systemic one which impacts inguinal and mediastinal nodes. After the implementation of 4 therapy cycles with Brentuximab vedotin, complete regression of the described by previous hospitalisations lymph nodes as well as 80% reduction of the cutaneous and subcutaneous located tumour formations were observed. CONCLUSION: The therapy of CD30+/ALK- anaplastic large T-cell lymphoma is a significant challenge for oncologists and dermatologists because it requires maximally efficient and minimally traumatic treatment in parallel. Therapy with Brentuximab is a new direction which shows extremely good clinical results and can be applied to the cutaneous as well as to the systemic form of anaplastic large-cell CD30 positive lymphoma. The key element by treatment with Brentuximab is suppression of the CD30- expression which, in turn, could be the cause of relapses. On that ground, patients with these lymphomas should be strictly monitored.

Comparative Analysis of the Applicability of Island Flap in Primary and Recurrent Basal Cell Carcinomas of Similar Localization.

BACKGROUND: Basal cell carcinoma belongs to non-melanoma skin cancers and is the most prevalent neoplasia that shows a tendency to increase over the last few decades. It occurs most often in skin areas exposed to sunlight. It is characterised by slow progression, low tendency to metastasising and good prognosis when the right choice of treatment has been made. The difficulty in the treatment of basal cell carcinomas is determined by their localisation and puts to the test the aesthetic potential of dermatosurgeons. Complete surgical excision is the standard approach in most uncomplicated cases. In relapsing basal cell carcinoma or carcinoma with aggressive or unfavourable histopathological characteristics, the clinician faces the dilemma of identifying the most appropriate method of treatment. To find the decision, help comes from the individualisation of each case and the related risk factors. CASE REPORT: Two cases of basal cell carcinoma of similar localisation are presented, where the carcinomas are removed using island flaps. In spite of the desire to observe the recommended field of surgical security (by the desire for the ultimate esthetic effect for the patient), one of the tumours was not completely removed, and as an alternative, reoperation was proposed using Mohs micrographic surgery (MMS). CONCLUSION: The choice of a surgical technique, which would guarantee a better outcome and could be applied depending on the individual risk factor in each patient, is discussed.

One Step Melanoma Surgery (OSMS) Without Using Ultrasonography for Preoperative Tumour Thickness Measurement? - "A Question that Sometimes Drives Me Hazy: Am I or Are the Others Crazy!"

BACKGROUND: One step melanoma surgery is a new surgical approach by which specific groups of patients with cutaneous melanoma may be operated only by or within a single surgical session. Until now, the Bulgarian Society for Dermatologic Surgery (BULSDS) has presented models of clinical behaviour, in which preoperative measurement of tumour thickness in combination with echographic measurement of the locoregional lymph nodes could lead to the conduct of the so-called one-step melanoma surgery. Although this one step surgery currently does not fit in the recommended guidelines, it ensures compliance of the recommended boundaries of operational security while saving patients a repeated excision and relieves the healthcare institutions or the patients themselves financially. CASE REPORT: We at this moment present another case from the Bulgarian Society for Dermatologic Surgery (BULSDS) of one step melanoma surgery with a perfect end result, where the tumour thickness was not preoperatively determined by high-frequency echography. Preoperative assessment of tumour thickness was performed based on the clinical picture and dermatoscopy. The histologically established tumour thickness was identical to the preoperative assessment, i.e. <1 mm. Removal of the melanocytic lesion was performed with operational security field of 1cm in all directions, where, as a rule, no further removal of the draining lymph nodes is required. CONCLUSION: One step melanoma surgery has two significant advantages: 1) it saves a re-excision in certain groups of patients, which in turn is 2) significantly more favourable from a financial point of view. Its applicability in the appropriate groups of patients and the postoperative (although in a limited number of patients) results achieved indicate the need to optimise the current algorithms and direct them individually to each patient. Guidelines may not and should not be unified or set strict limits given the fact that they show a significant level of variability themselves regarding some key moments in the initial surgical treatment of melanoma. More than 10% of the primary melanoma cases refer to thin melanomas, and dermatoscopy and clinics are a sufficient method of optimising the planned surgical excision.

Nevus Blue as a Sporadic Finding in a Patient with a Blue Toe?

BACKGROUND: Blue nevus is an interesting finding, which aetiology and risk of locoregional and distant metastasis have not yet been fully clarified. It may be inherited or acquired, with sporadic cases usually presented as solitary lesions. It is often localised in the area of the head and less often on the arms, legs or trunk. Blue nevi are formations with relatively low but still possible potential for switching to melanoma. CASE REPORT: The patient we described was hospitalised for pronounced cyanosis of the small toe of the right foot, accompanied by painful symptoms at rest and pain symptoms for a few weeks. Using inpatient paraclinical and instrumental tests, the patient was diagnosed with cholesterol microembolism. During the dermatological examination, blue nevus on the contralaterally localised limb was also diagnosed as a sporadic finding. According to the patient's medical history, the finding had existed for many years, but in the last few months, the patient has observed growth and progression in the peripheral zone of the nevus without any additional clinical symptoms. CONCLUSION: Due to the risk of progression to melanoma, the lesion was removed by radical excision, and the defect was closed by tissue advancement flap.

Pretibial Located Stewart-Treves Syndrome: Uncommon Presentation in a Bulgarian Patient!

BACKGROUND: The Stewart-Treves syndrome with localisation in the region of the lower extremities is not something unusual as clinical pathology, but the clinical diagnostics is rather difficult, and it can be further complicated maximally because of: the similar locoregional findings in patients with other cutaneous malignancies. CASE REPORT: Presented is a rare form of an epithelioid variant of the Stewart Treves syndrome in a woman, aged 81, localised in the region of the lower leg and significantly advanced only for 2 months. The diagnosis was confirmed histologically and immunohistochemically. Amputation of the affected extremity was planned. Discussed are important etiopathogenetic aspects regarding the approach in patients with lymphedema and possibility for development of the Stewart Treves syndrome. CONCLUSION: Analyzing the evidence from the literature worldwide, we concluded that perhaps the only reliable (to some extent) therapeutic option in patients with Stewart Treves Syndrome is 1) the early diagnostics and 2) the following inevitable radical excision or amputation with the maximal field of surgical security in the proximal direction.

Innovative One Step Melanoma Surgical Approach (OSMS): Not a Myth-It's a Reality! Case Related Analysis of a Patient with a Perfect Clinical Outcome Reported from the Bulgarian Society for Dermatologic Surgery (BULSDS)!

BACKGROUND: With the newly described one step melanoma surgical approach, some patient groups could be successfully treated within one surgical session. Depending on the tumour thickness (measured preoperatively) at a later stage (also depending on the ultrasound findings of the locoregional lymph nodes) the respective surgical intervention is planned with the respective field of surgical safety (one-stage melanoma surgery with or without removal of lymph nodes). The innovations could make to some extent some of the already existing algorithms more difficult (due to the introduction of a high-frequency ultrasound to determine the tumor thickness preoperatively as an absolute prerequisite for dermosurgical centres), but it would also lead with absolute certainty to better or least optimal results regarding the prognosis, the side effects and the financial factor also. CASE REPORT: We present a patient from the Department of Dermatology, Venereology and Dermatologic Surgery at the Medical Institute-Ministry of Interior (MVR-Sofia), treated with the one-step melanoma surgery method with perfect final results. The preoperative tumour thickness determined via ultrasound and the postoperatively measured histological tumour thickness was identical: between 0.98 and 1 mm, which allowed removal of the melanoma lesion with a field of surgical security of 1 cm in all directions and did not require additional removal of a draining lymph node or excisions. CONCLUSION: Thanks to this new approach, some patients could avoid one surgical intervention, which could be interpreted as a significant advantage or probably also survival benefit. This methodology and its successful application were first officialised by the representatives of the Bulgarian Society for Dermatologic Surgery- (BULSDS), and the purpose of this action, in general, is to fully improve clinical management of patients suffering from cutaneous melanoma in terms of compactness by 1) reducing the number of unnecessary surgeries or the number of surgical interventions in general; 2) reducing side effects occurring in surgeries and 3) introducing a serious optimization in terms of financial resources needed or used in the second hospitalization of patients. The question remains open whether the accepted or the current recommendations for surgical treatment of melanoma will be transformed or adapted for the matching patient groups.